A “payor” associated with an insurance program may facilitate payments made to health care providers. In the United States (“US”), for example, a payor might receive bills from a doctor, hospital, or pharmacy in connection with the Medicaid and/or Medicare insurance programs. Typically, health care provides use standard codes (e.g., describing treatments or medicines given to patients) and/or electronic transmission formats when submitting bills or claims to be processed by a payor. Moreover, the rules that govern such programs apply through the US and change relatively infrequently. As a result, the processing and review of these types of claims by a payor may be performed in a timely and efficient manner.
Claims associated with other types of insurance programs, however, may be more complex and time consuming to process. Consider, for example, a payor enterprise that arranges to provide payments to doctors, hospitals, and/or pharmacies in connection with the various workers' compensation insurance systems established throughout the US. Note that these programs are implemented on a state-by-state basis and different codes and/or transmission formats might be used by health care providers in different states. Moreover, different rules might apply to the processing of claims in each state (e.g., different rules associated with appropriate payment amounts). Still further, changes may be made to the rules on a relatively frequent basis (e.g., because fifty different states may review and adjust rules at various times). As a result, the processing of claims for these types of insurance programs may be complex, time consuming, and error prone and a payor may find it difficult to maintain an automated claims processing system.